Intrapartum care Flashcards
List 6 factors that affect a baby’s ability to rotate into the occiput-anterior position
- Inadequate uterine contractions
- Descent into pelvic floor, e.g. secondary to inadequate analgesia
- Poorly flexed cervical spine
- Maternal pelvis size and shape - cephalo-pelvic disproportion
- Fetal abnormalities - e.g. hydrocephaly
- LGA fetus
- Brow or face presentation
- Uterine abnormalities - bicornuate or fibroid uterus
- Oligohydramnios
Cochrane review: Instruments for assisted vaginal birth, 2021
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005455.pub3/full
- 31 studies (5752 women)
Findings:
Forceps (cf. vacuum delivery)
* Lower rate of failed instrumental birth, RR 0.58, CI 0.39 – 0.88
* Higher rate OASI, RR 1.83, CI 1.32 – 2.55
* Any maternal trauma may be slightly greater, OR 1.53, CI 0.98 – 2.4
* Lower rate of fetal trauma - cephalohaematoma, retinal haemorrhage, jaundice
No evidence of difference in PPH, low Apgar, low UA pH
Instrumental birth: when to abandon procedure
Ventouse =
* No progressive descent during each pull of a correctly applied instrument by an experienced operator
* Maximum three pulls to the perineum, three additional pulls to deliver the head out of the perineum
* Multiple pop-offs
○ RANZCOG - Up to three detachments generally acceptable, re-application of the cup on each occasion should only be considered where there has been definite progress with preceding pulls, or the head is on the perineum.
○ RCOG - discontinue after two pop offs, less experienced operators - seek support after one pop off
* Time to delivery >20 minutes
* If patient withdraws consent
Forceps =
* Unable to apply instrument or lock blades
* No progressive descent over contractions with moderate traction
* Delivery not imminent after 3 contractions when correctly applied instrument used by experienced operator
○ If there is minimal descent with the first one or two pulls of the forceps, the operator should consider whether the application is suboptimal, the position has been incorrectly diagnosed or there is cephalopelvic disproportion
Discontinue rotational forceps birth if rotation is not easily achieved with gentle pressure
Differences between cephalohaematoma and subgaleal haemorrhage
Cephalohaematoma =
* A haematoma that occurs beneath the periosteum
* Confined to one cranial bony plate (usually over the parietal or occipital bone)
* Soft fluctuant mass that does not cross suture lines
* Rarely expands after birth
* May completely resolve or calcify leaving a minor convexity to the cranial vault
Subgaleal haemorrhage =
* Bleeding that occurs due to shearing of blood vessels outside of the periosteum, below the epicranial aponeurosis (galea aponeurotica)
* This anatomical plane does not readily tamponade and persistent bleeding in this space may cause severe life-threatening blood loss
* Diffuse boggy swelling that crosses the midline, may shift with palpation, gravity dependent
* May increase head circumference, the eyelids may swell and ears can be displaced
* Can accommodate up to 250mL of blood with only a 1cm increase in scalp thickness, neonates can lose 70% of their circulating volume
* Blood volume of neonate - 90mL/kg
* Can lead to hypovolemia, anaemia, coagulopathy, shock, death
* Mortality rate - up to 25%
* Moderate to severe SGH - 1.5/10,000 births
What are 3 evidence-based strategies for reducing OASI injury and what is their level of evidence?
RCOG:
Warm compresses - level 1++
Perineal massage - level 1-
Perineal protection with crowning - level 2+
Mediolateral episiotomy with instrumental deliveries - level 2-
Immediate vs delayed cord clamping
Pros of delayed - term infants
- Improved haemoglobin and iron stores
Pros of delayed - preterm infants
- Improved transitional circulation, better establishment red cell volume, decreased need for blood transfusion, lower risk of NEC and IVH
Cons of delayed
- Increased hyperbilirubinaemia requiring phototherapy
- Small increased risk of jaundice in term infants
- Not able to resuscitate baby
